A home of their own: Vaya exceeds independent living goal despite pandemic

Jody – not their real name – was anxious for change. Amid mental health struggles and separation from a long-term partner, Jody had let go of one of their biggest passions – art – and constantly worried about next steps in life, including where to live.

That’s when Vaya Health’s Transitions to Community Living Initiative (TCLI) Team stepped in. Working closely with Jody and other Vaya staff, the team helped Jody move into a home of their own. Today, Jody drives their own car to and from appointments – formerly a major source of anxiety – and devotes time each day to art, which they sell both locally and online.

During the 12 months ending in June 2020, Jody was one of 82 members newly housed through Vaya’s TCLI program. That number topped the goal of 67 set by the N.C. Department of Health and Human Services – and during a pandemic. The year before, Vaya exceeded the state’s goal of 61, with 65 members newly housed.

TCLI, created through the state’s 2012 settlement agreement with the U.S. Department of Justice (DOJ), connects adults with serious mental illness to healthcare services and supports that help them maintain a home in their own name, instead of living in a facility. Vaya manages the program in 22 western North Carolina counties. At the end of June, 2,550 people lived in TCLI housing statewide, with the number of participants housed through Vaya in the past year helping the state exceed its current responsibility under the settlement by nine people. 

“When the COVID-19 outbreak started, much of the world came to a screeching stop,” said Celeste Ordiway, Vaya’s Central Director of Complex Care Management. “We problem-solved the barriers and found ways to continue to house people while maintaining social distancing. I couldn’t be prouder of the work that is happening to support our members and of how we overcame challenges along the way.”

At Vaya, the program is a team effort. Provider Network Operations staff are key to ensuring provider participation. Vaya’s Behavioral Health Crisis Line manages the referral process, and the Housing Team handles landlord outreach and communication, identifies vacancies and manages a database of leases. Once the transition is complete, participants are assigned a Vaya care manager for ongoing coordination of services and supports.

The heart of the program within Vaya is the TCLI Team. The team includes In-Reach Specialists and Transition Coordinators, who connect with eligible members interested in independent living and help them navigate the transition process with the support of their families and providers.

“The In-Reach Specialists and Transition Coordinators are the boots on the ground,” said Vaya Transition Coordination Manager Kelsie Kee Clark. “The team is committed to meeting or exceeding our goal and to truly helping people live in the community of their choice.”

That includes members like Jody, who has once again found confidence in themselves and “is conquering each day with passion,” Jody’s Transition Coordinator said. “The changes I have seen Jody make within the past year are remarkable, and I have no doubt they will continue to be successful in independent living.”

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